Bilateral Subdural Empyema in a 4-month-infant: An Unusual Complication of E.coli K1+ Bacterial Meningitis

Abstract

Background: Subdural empyema (SE) is a rare but life-threatening intracranial complication of Bacterial meningitis, occurring in approximately 1–2% of cases in infants. Prompt diagnosis and neurosurgical intervention are essential to reduce morbidity and mortality. Case Presentation: A 4-month-old immunocompetent female infant presented with high fever and lethargy. Blood, cerebrospinal fluid, and urine cultures confirmed infection with E. coli K1+. Despite treatment with a third-generation cephalosporin, persistent fever prompted neuroimaging. Brain CT and contrast-enhanced MRI revealed large bilateral subdural empyemas with associated meningitic changes. The patient underwent bilateral frontoparietal craniotomies with drainage of the empyemas and removal of pseudomembranes. Postoperatively, she experienced two focal seizures, which were successfully managed with levetiracetam. She completed a three-week course of cefotaxime and meropenem and was discharged on antiepileptic therapy. Discussion: Molecular analysis of the purulent specimen confirmed E. coli as the causative organism. Follow-up MRI performed six months after surgery demonstrated complete resolution of the empyemas, allowing discontinuation of antiepileptic therapy. At three years of follow-up, the child exhibited normal neurological development without residual deficits, highlighting the effectiveness of early diagnosis, aggressive antimicrobial therapy, and timely neurosurgical management. Conclusion: Bilateral subdural empyema is an uncommon but serious complication of E. coli K1+ bacterial meningitis in infants. Early recognition through advanced neuroimaging, prompt surgical drainage, and appropriate antimicrobial therapy can result in excellent long-term neurological outcomes.